Cook et al 2009 — Prevalence of Psychiatric and Substance Use Disorders Among Single Mothers Nearing Lifetime Welfare Eligibility Limits

Summary

First comprehensive diagnostic study (Composite International Diagnostic Interview (CIDI) 2.1 full battery, DSM-IV) of psychiatric and substance use disorders in a randomly sampled population of single mothers nearing the federal 5-year lifetime Temporary Assistance for Needy Families (TANF) eligibility limit. $N = 333$, Cook County IL, November 2003–October 2004. Found 12-month mental disorder prevalence of $44.1\%$ — more than double the national rate for US women — with two-thirds of diagnosed women completely untreated. Women who worked more months were one-third as likely to receive any behavioral health treatment, documenting a structural employment-treatment tradeoff.

Key Claims

• 12-month any DSM-IV disorder: $46.8\%$ ($95\%$ confidence interval (CI), $41.5\%$–$52.2\%$); lifetime $61.0\%$
• 12-month mental disorder: $44.1\%$ (vs. $\approx 22\%$ national rate for women); lifetime $53.2\%$
• 12-month major depression: $17.4\%$ (vs. $8.6\%$ US women in National Comorbidity Survey Replication (NCS-R))
• 12-month anxiety disorders: $39.0\%$ (vs. $23.4\%$ US women); PTSD $9.3\%$; specific phobia $21.9\%$; generalized anxiety disorder (GAD) $7.5\%$
• Substance use: 12-month drug abuse/dependence $5.4\%$ (vs. $0.7\%$ US women); alcohol abuse/dependence $5.1\%$ (vs. $1.8\%$ US women) — $5\times$ and $\approx 3\times$ national rates respectively
• Comorbidity: $>75\%$ of those with 12-month mood disorder also met criteria for anxiety disorder; $50\%$+ of those with anxiety disorder met criteria for mood disorder
• Recurrence predominates: most 12-month disorders are recurrent, not incident — indicating chronic conditions predating welfare receipt
• Treatment gap: only $21.7\%$ of those with 12-month mental disorder received any mental health treatment; $41.4\%$ of those with substance use disorder received treatment; $66\%$ of all DSM-IV cases completely untreated
• Employment-treatment tradeoff: controlling for all covariates, women employed 7–12 months in past year were only one-third as likely to receive any behavioral health treatment (OR $= 0.3^{*}$, $p < 0.05$) vs. those not working
• Protective factors: cohabitation with intimate partner → significantly lower odds of mood and anxiety disorders (lifetime OR $= 0.4^{*}$); education $\geq 12$ years → lower anxiety disorders
• Risk factors: ever-married status → higher odds of mood (OR $= 2.2^{*}$) and anxiety (OR $= 2.8^{**}$) disorders; older age → higher substance use disorder prevalence
• Sample: $95.8\%$ African American; mean age $32.3$ years; mean $4.0$ children; never married $87.4\%$; mean $15.4$ months remaining TANF eligibility; only $27.3\%$ employed 7–12 months in prior year

Concepts Introduced or Extended

• TANF and Mental Health
• Deserving Poor

Entities Mentioned

• Judith A. Cook

Quotes

"Despite the high prevalence of psychiatric and substance use disorders in this population, many remain untreated. The consequences of terminating welfare assistance are worthy of further investigation, given the potential for adverse effects on both mothers and their young children."

"Of particular concern is the finding that, controlling for all other factors, women with DSM-IV disorders who were employed a greater number of months in the past year were only a third as likely to receive any type of behavioral health services as those working fewer months or not at all."

"Given the work-first policies promoted by welfare reform, available TANF services may be ill matched to some recipients' levels of need."

My Take

This paper documents a major unmet need at precisely the worst moment: women within 24 months of the federal TANF cliff, with $44\%$ 12-month disorder rates and $66\%$ untreated. The employment-treatment tradeoff finding (OR $= 0.3$) is especially troubling because it implies that work-first welfare reform may actively undermine the treatment-seeking that would enable stable employment. The sample is almost entirely African American women in Cook County IL ($95.8\%$), which limits generalizability, but the mechanism findings should be broadly applicable. The CIDI 2.1 full battery is gold-standard for diagnostic epidemiology; the authors are honest about the lack of functional impairment data. The link to supported employment (Cook cites her own Employment Intervention Demonstration Program (EIDP) work as a potential intervention for this population) is suggestive but speculative — TANF recipients are generally not enrolled in mental health treatment systems that provide supported employment (SE) access.